Medicine’s Search for Meaning

Every day, we are reminded that the health care system is in crisis. We are going bankrupt. There are too many lawsuits. We practice defensive medicine. We restrict access. But surveys of doctors indicate a problem that penetrates much deeper than this. Today, almost 50 percent of doctors report symptoms of burnout — emotional exhaustion, low sense of accomplishment, detachment.

Countering doctor burnout with a refresher course on the capacity to heal.

Medicine is facing a crisis, but it’s not just about money; it’s about meaning.

We often think of medicine as a science, and many doctors do come to think of themselves as technicians. But healing involves far more than knowledge and skill. The process by which a doctor helps a patient accept, recover from, adapt to, or endure a serious illness is full of nuance and mystery. I was often moved by how much my father-in-law — an actor who died from a form of leukemia — drew comfort and even inspiration from the relationship he had with his hematologist (who requested a Shakespeare recitation at each visit).

Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Declaration of Geneva (“I solemnly pledge to consecrate my life to the service of humanity…”) or the Oath of Maimonides (“May I see in all who suffer only the fellow human being.”)
Yet by then, considerable damage has already been done. Nearly half of medical students become burned out during their training. Medical education has been characterized as an abusive and neglectful family system. It places unrealistic expectations on students, keeps them sleep-deprived, overstressed, and in a state of fear of making mistakes, and sends the message that doubts or grief should be kept to oneself. While the training formally espouses the ethics of empathy, compassion and altruism, doctors and researchers say that the socialization process — the “hidden curriculum” — teaches something very different: stay detached, objective, even a little cynical. Five out of six doctors say that medicine is in decline and close to 60 percent would not recommend it as a career for their children (pdf).

As administrative and documentation burdens have exploded in the past three decades, doctors find themselves under pressures to work as quickly as possible. Many have found that what is sacrificed is the very thing that gives meaning to the whole undertaking: the patient-doctor relationship.

“These high levels of distress, depression, loss of satisfaction, fatigue, and burnout have big repercussions for quality of care,” explains Dr. Tait Shanafelt, director of the Mayo Clinic Department of Medicine’s program on physician well-being. It leads to medical errors, substance abuse, and doctors quitting — something that a country with an aging population and a shortage of doctors can ill afford.

How could we help medicine overcome its own illness?

That’s a question that has occupied Dr. Rachel Naomi Remen for decades. Remen is a clinical professor of family and community medicine at the U.C.S.F. School of Medicine and the director of the Institute for the Study of Health and Wellness, at Commonweal. Over the past 22 years, she has been advancing a powerfully subversive addition to the medical curriculum, a course called The Healer’s Art.

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For the first six years, Remen taught it with 10 friends, all community physicians drawn from outside the school. She was half afraid that her dean would discover it and throw her out. But gradually, the course began to spread by word of mouth, to two schools, then four, then 16, then 25. It is now taught annually at 71 schools in the United States (half of the nation’s medical schools) and schools in seven other countries.

More than 1,600 students take the course each year and about 13,000 have gone through it. And while it is described as a simple elective — a 15-hour course given in five three-hour sessions — many of the doctors who teach it, and the students who take it, see it as part of a movement. In evaluations, large majorities of students say the course fills a gap in their medical education. It helps them to feel more committed to medicine, more supportive of their classmates, more confident that they can be good doctors, and more clear about what they can personally offer patients. More than 95 percent of them say they will recommend it to other students.

“What our students say loud and clear is this course helps to keep their spirits alive as they go through the training,” explains Nancy Oriol, dean for students at Harvard Medical School.

Remen’s life has been shaped by her own experience living with illness. By her own admission, she has not been well for 60 years. When she was 15, she was diagnosed with Crohn’s disease. She underwent nine major surgeries and took large doses of steroids daily for 15 years. “My doctors told me I would be dead by the time I was 40,” she says with a laugh. She’s now 75 and has been a doctor herself for 50 years.

After medical school, on her first day in training as an intern, a 3-year-old was brought into the emergency room after a car accident. The doctors were unable to save the child’s life. Remen accompanied the chief resident as he met with the parents to inform them that their child had died. When they broke down, the sadness was too much. Remen found herself crying, too.

Afterward, the chief resident took Remen aside and said that her behavior had been highly unprofessional.

The message stuck. By the time Remen was senior resident, she hadn’t cried for years. That year, another child, a baby, was brought into the hospital after drowning unattended in his bathtub. The doctors were unable to resuscitate the baby. This time, Remen was the one responsible for informing the parents that their only child had died — and as they held each other and fell apart sobbing — she stood silently by in her white coat, maintaining her professional distance. After a while, the baby’s father, with tears running down his face, apologized. “‘I’m sorry, doctor,’ he said. ‘I’ll get a hold of myself in a minute.’”

How had she become the person a grieving father apologizes to? This is a common outcome of the hidden curriculum.

Medicine’s ‘hidden curriculum’ teaches that doubts and grief are forbidden.

The Healer’s Art is predicated on the idea that medicine is an ancient lineage that draws its strength from its core values: compassion, service, reverence for life and harmlessness. When students and doctors connect to these values in a community, they derive meaning and strength, and can “immunize” themselves against the assaults of the medical curriculum and even the health care system itself.

To help people tap into these deep currents, the course is delivered in an unusual manner. Students and faculty members meet together in small groups in the evenings, participating side by side as equals. There are no experts, no hierarchies, no wrong answers; anyone may speak about his or her experiences or simply listen.

It begins by reminding people that it is not by chance that they are in the room. “We ask: ‘How old were you when you first realized that the needs of a living thing mattered to you?’” says Remen. “For most doctors and students, the impulse to respond to the needs of others, plants, animals, insects, and even people, goes back to early childhood, sometimes as far back as they can remember.”

Remen recalled a student who told the class that his mother used to bathe him in an old claw-footed bathtub. “At the end of his bath, she would pull out the stopper, reach behind him and get a towel, sit him on her lap and dry him. One day he stepped on the drain and it was sharp — there was pain and blood — and his mother said, ‘Never stand on the drain again.’ A few weeks or months later, as he was waiting for her to dry him, he noticed the water circling the drain as the tub emptied. He remembered how sharp the drain was and worried that the water was being hurt. After that, when his mother pulled the plug, he would drop his washcloth over the drain to protect the water.

“This is magical thinking. He was probably about 3,” said Remen. “Now he is a pediatrician and he brings the same intention to make a difference in pain and suffering to his little patients himself.”

Every culture approves and disapproves of different qualities. As the price of admission, medicine implicitly asks its members to leave aspects of themselves behind. The course explores this idea, what Carl Jung called the “shadow.”

“Everybody’s given a box of crayons and a big piece of paper like in first grade and they are asked to draw a picture of the parts of themselves they feel they can’t bring into their work as doctors,” explains Joseph O’Donnell, a Senior Advising Dean at the Geisel School of Medicine at Dartmouth, who has taught the course for more than a decade. First-year students do the exercise alongside doctors who have been practicing for decades. “Then everyone holds up their picture. You see ‘curiosity,’ ‘love,’ ‘compassion,’ ‘kindness,’ ‘creativity.’ And people say, ‘I thought I was the only one experiencing this.’ ”

The session on grief and loss is among the most powerful, adds O’Donnell. “Students and faculty are asked to become still and quiet,” he explained. “They’re asked to think back to a time when they experienced a loss, and remember the feelings, and think about what someone may have done that was helpful, or unhelpful.”

They write it down. Then the students are asked to say what was helpful. “You hear things like: They held my hand. Gave me a hug. Brought me food. Sat silently and listened.” For unhelpful, you hear things like, “They said, ‘I’d better leave you alone” or “You’ll be fine in no time.'”

When O’Donnell graduated from medical school in 1973, there was no place to discuss such matters openly. “It wasn’t safe to say, ‘I’m really bothered by what I’m seeing today.’ You just took care of it. You read the scientific articles, but you put your heart and soul aside. Here you are allowed to bring those things to the forefront in a valid way with colleagues who are esteemed.”

Dean Parmelee, the Associate Dean for Academic Affairs at Wright State University, who has taught the course for several years, recalled an incident shared by a fourth-year student who had been part of a team when a baby was stillborn.

The mother was 16 or 17 years old and she was with her boyfriend, he recalled. There were some psychosocial issues. “After the delivery, the student said, shockingly, everyone just left the operating room,” said Parmelee. “He was the only person left and the only sound was the air-conditioning and the ventilation.” The mom had started to cry; her baby lay still on her abdomen. The boyfriend was crying, too. The student said nothing. He simply reached out and took the mother’s hand and with his other hand he reached out and took the father’s hand, closed his eyes and stood there with them for a few minutes crying silently together.

“The student said that if he hadn’t taken the course, he would have left the room like everyone else,” added Parmelee. “Or he might have said something like, ‘You’re young, you can have another baby.’ ”

“Instead,” commented Remen, reflecting on the story, “he offered them and himself the healing of a common humanity.”

‘I saw that you don’t have to become hardened,’ a medical student said.

This is not how doctors are accustomed to managing grief and loss. “We intellectualize it, minimize it, become numb to it,” O’Donnell said.

There is an enduring belief in medicine that if you feel strongly it will cloud your judgment. But research indicates that emotional attunement can improve critical thinking, decision-making, and the ability to act quickly in crisis moments.

Moreover, we need to feel to connect with other human beings. “If patients see that you care, they can trust you enough to tell you the truth and are more likely to follow your advice,” observes Remen. Parmelee, who has been an expert witness in malpractice cases, has found that most cases boil down to physicians “not really listening or making themselves available emotionally for a patient.”

And then there is the simple truth that buried feelings don’t just go away. “When I took The Healer’s Art, the session on grief and loss brought up a whole period in my life that I must have tried hard to not think about,” recalled Parmelee. “I was totally unaware of its continuous impact on me, and how much was still there after more than 30 years.”

In medical school, students rarely hear their teachers speak this way. Brent Aebi, a third-year medical student at Wright State University, said that hearing veteran doctors speak about their struggles helped him to see a path forward that felt right to him. “I saw that you don’t have to become hardened,” he said.

The same holds for peers. The combination of hyper-competition and self-doubt in medical school can work against the development of supportive relationships. “This way of listening to others’ stories is not present in the normal medical training,” observes Rhianon Liu, a third-year medical student at Johns Hopkins School of Medicine. “And it showed me that the most important protective mechanisms are the relationships we build with our classmates and faculty.”

Indeed, the importance of listening comes across as one of the course’s biggest lessons. “Students comment that they never realized how powerful silence is in communication,” said Parmelee.

For O’Donnell, who oversees oncology at the Veterans Administration Hospital in White River Junction, Vt., the course has helped him learn to listen more deeply. “I hear themes I might have missed before,” he says. “Not just the symptoms, but the story — how scared the patient is that this ache might mean a recurrence. It brings you back to taking care of people. Because the world isn’t made up of atoms. It’s made up of stories.”

The Healer’s Art is an entry point: an attempt to anchor a cultural shift in medicine. Some students who have taken the course have formed groups so they can continue to uncover the meaning of their work after the course ends. They are building an alternative socialization process. The Institute for the Study of Health and Illness also helps doctors, nurses and other health care professionals form groups dedicated to “Finding Meaning in Medicine.”

But the course and similar programs need to be given much higher priority if we are going to attack burnout. “Because it has strong links to the quality of care,” says Dr. Shanafelt of the Mayo Clinic, “promoting wellness is a shared responsibility of individual physicians as well as the hospital or practice group.”

However, if hospital administrators are going to allow doctors to cut back on “productive” activities so they can take time to focus on self-care, he adds, “We’ll need to provide hard evidence for people making financial decisions that this is a good investment.”

For doctors, this investment could mean the difference between succumbing to burnout and finding ways to practice that deepen their sense of purpose. “When doctors learn to read the affective domain, they are shocked to discover that they have gone right past experiences of profound meaning without seeing them,” says Remen. “They say, ‘I was colorblind.’ Medicine offers you a front-row seat on life. Meaning is all around you. When you can see it, it gives you a sense of gratitude for the opportunity to do this work.”